New Patient Intake Form
Name: ___________________________________________________________
Date: _______________
Address: ____________________________________________________
Birth Date: _____ /_____/_____
City: ______________________________ State: ____
SS#: _______-______-________
□ Male □ Female
Zip ________
□ Single □ Married □ Divorced □ Widowed
I give The Center for Spine, Sport and Physical Medicine permission to leave messages pertaining to my
appointment. □Yes □ No
Home: _______________________________________ Cell Phone: _____________________________________
Work Phone: _____________________________________ E-mail:______________________________________
How did you hear about us? _____________________________________________________________________
Emergency Contact:___________________________________________ Relationship:_____________________
Phone #:____________________________________________________
INSURANCE INFORMATION:
Insurance Company: _______________________
ID #:____________________________________Group # (Include any letters):____________________________
Primary Policy Holder’s Name: ______________________________
Relationship to policy holder: □ Self □ Spouse □ Child
Policy holders DoB: _____/_____/_____
Did this condition arise as a result of a motor vehicle accident or work injury? No_____
Yes_____
Claim #:_______________________________________________
Date of injury: ______/_____/______
Adjuster’s Name: _______________________________________
Phone#: ________________________
Claims address: _______________________________________________________________________________
Have you retained an attorney? No___ Yes___ Please provide name and contact information below:
Page 1 of 5
HEALTH HISTORY
Have you been hospitalized overnight and/or had any prior surgeries?
□ No □ Yes
Please list below:
____________________________________________________________________________________________
____________________________________________________________________________________________
Are you currently taking prescription medication? □ No □ Yes Please list:______________________________
____________________________________________________________________________________________
Please list any allergies (environmental, food, medications, latex, other):__________________________________
____________________________________________________________________________________________
□ No □ Yes How many cigarettes/packs per day? ___________ For how long? ___________
Do you drink alcohol? □ No □ Yes How often? _________________________________________________
Do you use drugs/substances not prescribed by a physician? □ No □ Yes Please describe: _______________
Do you smoke?
____________________________________________________________________________________________
Is there a family history of cancer or other disease?
□ No □ Yes
please list: __________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Pain Diagram: Please mark the areas of complaint on the diagram using the symbols on the left
Sever Pain
Aching
^^^
Numbness
+++
Pins and
Needles
OOO
Burning
XXX
Stabbing
/////
No Pain
Please indicate the
severity of your pain
currently on the line
above
Patients Signiture___________________________________________________ Date:______________________
Page 2 of 5
REVIEW OF SYSTEMS
Please mark all that apply:
Patient signature ____________________________________________________ Date:______________________
General□ Weight loss or gain
□ Fatigue
□ Fever or chills
□ Weakness
□ Trouble sleeping
Skin□ Rashes or Itching
□ Change in color
□ Change in hair or nails
□ Non-healing sores
□ Dryness
□ Change in appearance of mole
□ Breast Pain
□ Breast Lumps
□ Breast Discharge
Eyes□ Wear glasses/contacts
□ Vision Loss/Changes
□ Pain
□ Redness
□ Blurry or double vision
□ Flashing lights
□ Specks
□ Glaucoma
□ Cataracts
□ Eye disease or injury
Ears- Nose- Throat□ Bleeding gums
□ Bad breath or bad taste
□ Mouth sores
□ Dry mouth
□ Hoarseness
□ Sore throat or voice change
□ Swollen glands in neck
□ Hearing loss
□ Ringing in ears
□ Earache
□ Sinus Problem
□ Stuffiness
□ Drainage
□ Itching
□ Nosebleeds
Respiratory□ Persistent cough
□ Coughing up blood
□ Shortness of breath
□ Wheezing
□ Asthma
□ Painful breathing
Cardiovascular□ Chest pain or discomfort
□ Sudden changes in heartbeat
□ Shortness of breath with
activity
□ Difficulty breathing
□ Swelling on feet, ankles, hands
□ Heart trouble
Neurological□ Frequency or recurrent
headaches
□ Lightheadedness or dizziness
□ Fainting
□ Convulsions or seizures
□ Numbness or tingling
Gastrointestinal□ Stomach pain
□ Heartburn
□ Change in appetite
□ Nausea or vomiting
□ Blood in stool
□ Change in bowel habits
□ Painful bowel movements
□ Constipation
□ Diarrhea
Endocrine□ Thyroid problems
□ Diabetes
□ Excessive thirst or urination
□ Cold extremities
□ Heat or cold intolerance
□ Change in glove or hat size
□ Dry skin
□ Glandular or hormonal
problems
Genitourinary□ Sexual difficulty
□ Kidney stones
□ Burning or painful urination
□ Blood in urine
□ Incontinence
□ Change in force or strain with
urination
□ Frequency Urination
Mind/ Stress□ Nervousness
□ Depression
□ Sleep problems
□ Memory loss or confusion
Musculoskeletal□ Stiffness or swelling of joints
□ Weakness of joints or muscle
□ Muscle pain or cramps
□ Neck pain
□ Upper or mid-back pain
□ Low back pain
□ Joint pain
□ Difficulty walking
Hematologic□ Swollen glands
□ Ease of bruising or bleeding
□ Anemia
□ Phlebitis
□ Transfusion
□ Slow to heal after cuts
Woman Only□ Irregular periods
□ Painful periods
□ Vaginal discharge
□ Date of last menstrual
period:__________
Page 3 of 5
FINANCIAL POLICY
Please read and initial each statement:
______Payment is due at time of service unless arrangements have been made in advance. You are financially
responsible to us for all cash fees, co-payments and any amount your insurance company deems your responsibility
such as deductibles and co-insurance, as well as denials for services not covered under your policy. We accept Visa,
Discover, MasterCard, American Express, checks and cash. Please note: if paying by check, you agree to pay in full
all dishonored checks plus a processing fee.
______ Not all insurance plans cover all services. In the event that your insurance plan determines a service to be
"not covered", you will be responsible for the complete charge. Payment is due upon receipt of statement from our
office.
______ We file insurance claims with your individual insurance company as a courtesy to you. However, your
insurance policy is a contract between you and your insurance company. As the patient, you are ultimately
responsible to us for payment for services rendered.
______We verify your insurance benefits as a courtesy to you. Verification of benefits does not guarantee
payment by your insurance company as there may be other restrictions included in your policy not given to our
staff in the verbal or written benefit description. It is your responsibility to understand your benefits and what is
covered under your plan.
______ It is your responsibility to inform us of any changes in your insurance coverage. Timely filing deadlines
do exist and you will be financially responsible for any charges that are incurred as a result.
Only after exhausting our internal attempts for payment, we will send a delinquent account to our collection agency
or small claims court. Any collection fees, court costs, or reasonable attorney fees are the responsibility of the adult
person(s) named on the account. Monthly service fee of 1.5% per month or 18% per annum will be assessed on all
past due accounts. You will be required to pay your account in full before scheduling another appointment if your
account is in collections.
CANCELLATION/MISSED APPOINTMENT POLICY
In order to better serve our patients and ensure that our providers are compensated for their time, we require at least
24-hour advanced notice if you will be unable to attend your appointment.
A cancellation that is less than 24 hours prior to your scheduled appointment will be considered a missed
appointment and you will be responsible for the full price of the appointment. Late cancelation/missed appointment
charges cannot be submitted to insurance or injury claims and will be charged at our cash fee rates listed below.
30 minute massage therapy session.
60 minute massage therapy session.
Acupuncture appointment.
Chiropractic appointment.
$40.00
$75.00
$75.00
$70.00
I have read and understand the above FINANCIAL POLICY, and CANCELLATION POLICY and I agree to be
bound by its terms.
Name of Patient(PLEASE PRINT):_______________________________________ Date_____________________
X___________________________________________________________________
Signature of Patient (or Responsible Party if minor)
Page 4 of 5
CONSENT TO TREATMENT
I hereby give permission to the doctor to release any information requested by my insurance company, physicians,
or other health care providers acquired in the course of my examination and treatment. I also give consent to submit
request(s) for any information from my insurance company, physicians, or other health care providers. I hereby
authorize and direct my insurance benefits to be paid directly to the doctor. I am financially responsible for noncovered services. I hereby give permission to the doctor and/or therapist to administer treatment and perform such
general procedures as he/she may deem necessary in the diagnosis and/or treatment of my condition. I fully
understand that this consent will remain in effect until revoked in writing. I have read and I do understand and agree
to the above statements.
NOTICE OF PRIVACY POLICY
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain
rights to privacy regarding my protected health information. I understand that this information can and will be used
to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be
involved in that treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your NOTICE OF PRIVACY PRACTICES wherein a more detailed
description of the uses, examples of and disclosures of my personal health information (“PHI”) exists. I understand
that this organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I
may contact this office at any time if I wish to obtain a current copy of the NOTICE OF PRIVACY PRACTICES.
Name of Patient(PLEASE PRINT):_______________________________________ Date_____________________
X___________________________________________________________________
Signature of Patient (or Responsible Party if minor)
Page 5 of 5